Provider Demographics
NPI:1427268952
Name:RYAN, MARY T (MS, RD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:T
Last Name:RYAN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:T
Other - Last Name:HOWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, PCSW
Mailing Address - Street 1:PO BOX 1076
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1076
Mailing Address - Country:US
Mailing Address - Phone:073-690-5785
Mailing Address - Fax:
Practice Address - Street 1:535 CACHE CREEK DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8653
Practice Address - Country:US
Practice Address - Phone:307-690-5785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8001041C0700X
WY886773133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116673500Medicaid